Bell’s Palsy

January 20,2010
 History
- Sir Charles Bell, Scottish
Surgeon
- First described in early
1800s based on trauma
to facial nerves
- Definition of Bell’s
Palsy: Acute peripheral
CN VII (facial nerve)
palsy of unknown cause
 Anatomy

1) Motor to facial muscles

2) Parasympathetic innervation to lacrimal, submandibular, sublingual salivary glands
3) Afferent fibers for taste on anterior 2/3 tongue
4) Somatic afferents to external auditory canal & pinna
 Epidemiology
• ½ of all facial palsy’s qualify as “Bell’s Palsy”

• Annual Incidence 10-40/100,000

• Lifetime incidence 1:60

• Risk is 3xs greater in pregnancy, especially 3rd

trimester

• Increased risk with diabetes

 Cause
• Widely accepted cause is HSV-1, however not
proven

• HSV mediates inflammatory/immune

response which leads to myelin sheath
degeneration, & edema which causes
compression and further damage of CN VII
Clinical Features
• Sudden onset symptoms,
usually hours w/ maximal
weakness w/in 48 hrs
• Unilateral
• Eyebrow sagging
• Inability to close eye
• Loss of nasolabial fold
• Decreased tearing
• Hyperacusis
• Loss of taste to anterior 2/3
tongue
• Mouth droop
 Differential Diagnosis
• Infection • Metabolic
– External otitis Otitis media – DM
– Mastoiditis – Hyperthyroidism
– Chickenpox – Vitamin A deficiency
– Herpes zoster (Ramsey Hunt • Toxic
syndrome) • Iatrogenic
– Encephalitis Poliomyelitis (type I) • Idiopathic
– Mumps – Bell's
– Mononucleosis – Melkersson-Rosenthal syndrome
– Leprosy (recurrent alternating facial palsy,
– Influenza furrowed tongue)
– Coxsackievirus – Amyloidosis
– Malaria – Landry-Guillain-Barre syndrome
– Syphilis – Multiple sclerosis
– Tuberculosis – Myasthenia gravis
– Botulism – Sarcoidosis
– Lyme disease • Birth
• Tumor, central or local • Trauma
 Ramsey Hunt Syndrome
• AKA Herpes Zoster Oticus: Reactivation of
VZV within geniculate ganglia
• Lifetime incidence VZV 10-20%; if live to
be 85, 50%
• Risk Factors: Age, Malignancy,
Immunosuppressed
• Pathophysiology:
• 1) Age related immunosenescence
• 2) Disease associated
immunocompromise
• 3) Iatrogenic immunosuppression
• Clinical Features
• Acute Vertigo
• Hearing loss
• Ipsilateral facial paralysis
• Ear Pain
• Vesicular rash
• Rx: Steroids, acyclovir
 Evaluation & Diagnosis
• Bell’s Palsy is a clinical • Proceed with imaging
diagnosis based on (MRI) if
– typical presentation – Atypical Presentation
– absence of other – Slowly progressive over 2-3
explanation or other weeks
underlying disease – If no improvement in
– absence of cutaneous symptoms in 6 wks
lesions • Electrophysiology (CMAP)
– otherwise normal neuro performed if complete
exam
facial paralysis remains
• Possible Labs to check: after 1 week of treatment
ESR, RPR, Lyme titer,
glucose, PCR if vesicular
lesions
 Treatment
• Manual closing of eye such as with tape while
sleeping, lubricating eye drops
• Steroids 60-80 mg daily x 5 days then tapered
over next 5 days or 1 mg/kg daily x 7 days
• +/-Acyclovir 400 mg 5xs daily x 10 days vs
Valacyclovir 1 g BID x 7 days
• Surgical Decompression – no good evidence to
support
 Prognosis
• 80% recover within weeks to months

• If motor nerve conduction studies show

evidence of denervation after 10 days
indicates prolonged recovery of ~ 3 months &
possible incomplete recovery